Lawrence and I had a fantastic week. The list of cases does not really do them justice. The retroperitoneal tumor cases had the portal vein and SMV splayed over it. I originally thought it was unresectable but the poor girl was only 17 so I tried. I ended up debulking it and hope it was a neuroendocrine tumor. We introduced the concept of “Damage Control Elective Surgery in a Resource Constrained Environment”. We had only one unit of blood (we were called to the OR to help others who started the case and first met the patient on the OR table). I packed the patient and took her back to the OR the next day for definitive closure after resuscitating her in the ICU. She is now fine. The next day we did a gigantic spleen with a splenic artery aneurysm. The spleen was the most difficult I have ever done with extensive adhesions and I originally thought the splenic artery aneurysm was a tumor in the tail of the pancreas as it was rock hard until I realized it was pulsatile and expansile. The incarcerated scrotal hernia case had a liter of intestinal contents in the tunica vaginalis. We opened the abdomen and controlled the blood supply of the incarcerated viscera before opening the rectus for about 2 cm to permit reduction of the hernia—another great case.

On Thursday I drove 12 hours to a Mission Hospital at Haidom, a place in the middle of nowhere, two hours by dirt road from the nearest town on a maintained road. One of the Tanzanian residents invited me to visit his home hospital. Most of the surgery there is done by assistant medical officers—non MDs who are trained to do surgery. One I met there is about my age and a reasonably skilled orthopedist who was also doing burr holes and prostatectomies. While there, I did a suprapubic prostatectomy and helped an assistant medical officer re-explore an abdomen two weeks after a hysterectomy—she began to discharge blood from the vaginal cuff. The abdomen was filled with old clot and the intestines had multiple points of obstruction but we found no definite source of bleeding. The burden of disease there was immense. The wards were filled with patients, literally about six inches between the beds so that you could hardly move between the beds. I saw a 25-year-old man with a large untreated malignant melanoma of the foot, a groin full of nodes and the largest liver I have seen in quite some time obviously filled with tumor. They next presented a 30-year-old very wasted man with a huge retroperitoneal tumor that looked like it was going to necessitate out of the abdomen. Finally, I saw a poor woman with a fungating carcinoma of the breast who unfortunately also had a malignant pericardial effusion with tamponade physiology. There was a five-year-old boy who had been bitten by a snake and had had a fasciotomy. He had a large granulating wound of the leg. I was going to cover it with a skin graft but the anesthetist and the nurses decided he was not ready for a graft!! There were no trained surgeons in the entire hospital. Those are the patients I saw, and there were many more.

Lawrence and Jessica are leaving tomorrow to attend the annual meeting of the Congress of Surgeons of Eastern, Central and Southern Africa in Addis Ababa, Ethiopia. This is a wonderful opportunity. Jessica is presenting data on the epidemiology of inguinal hernia in Tanzania. We listened to her presentation this morning and it is excellent. I will continue to work here clinically with the Tanzanian faculty and staff for the week they are away.

This week there were relatively few cases however the complexity of the cases continue to increase. Of note, there was very complex pancreatic pseudocyst and a large right colon cancer invading the abdominal wall involving the right adnexae, a large portion of the ileum, the sigmoid colon and the lateral wall of the duodenum. Lawrence has already done his third splenectomy after being on the service two weeks. He also has two colostomies as well as having participated and done significant portions of two very complex right hemicolectomies, an abdominoperineal resection for a large, bulky rectal cancer invading the vagina, the pancreatic pseudocyst and a strangulated inguinal hernia requiring a bowel resection. He also scrubbed on a very difficult large bowel intussception with a cecal tumor intussucepting all the way to the rectum.

The academic and non-operative portions of the program continue as per the reports in the previous weeks.

Eveline Shue finished her one month clinical rotation with us last Friday and returned to the United States on Monday, November 19. Unfortunately, one of the senior faculty members died last week and therefore the operative list last Wednesday was cancelled so that everyone could attend the funeral. Therefore, the operative load was lighter than in previous weeks. However, we helped one of the young faculty members complete the first laparoscopic cholecystectomy since SAGES held a course here several months ago. They are very keen to develop a laparoscopic program here and UCSF has the potential to be a great help.

We finished the week with two challenging cases: one was a large right colon cancer invading the abdominal wall associated with a large abdominal wall abscess. Unfortunately the patient had carcinomatosis but we were able to get the primary out, do a primary anastomosis and she is already eating. Hopefully we won’t have any complications and she can enjoy what time she has left. Tragically, she is only 22 years old. The second case as a large adenocarcinoma of the rectum. Lawrence had a major role in the APR which included an enbloc resection of the posterior wall of the vagina. The young Tanzanian faculty members were very kind to invite me to help them with these cases which also gave good exposure to our residents.

One of the problems we had was that Jessica and Eveline were rotating at the same time which means that they had to share the operative cases. On the one hand it was a good social experience, especially since Jessica is fluent is Swahili. Eveline managed to learn a great deal of Swahili in one month. On the other hand, it cut down on their individual case load. Nevertheless, they were both exposed to all the cases. Lawrence is now the only American resident on the service and I hope he will do more cases although he and Jessica will attend a meeting of the Central Eastern and Southern Africa Surgical Congress in Addis Ababa, Ethiopia, later this month. I think that meeting will also be a great opportunity to learn more about Surgery in Africa and network with more African surgeons. However, it will take away from the clinical experience but I think it is an opportunity not to be missed. I will stay in Dar Es Salaam and continue to represent UCSF to Muhimbili so that they see that we do is what we say we will do.

On a personal level, relations with the Tanzanian faculty and residents appear to be excellent. I have been invited to several homes and am continually consulted on challenging cases from both Firms even though I am officially attached to Firm 1. We attend all teaching conferences religiously and stay in Theatre continuously on our assigned days so we are scrubbed most of the time.

Jessica Beard completed her four-week rotation this past week. She will continue to do her research projects here in Tanzania, one of which involves teaching laparoscopic skills in trainers to Tanzanian residents and faculty members. We had a ceremony handing over laparoscopic instruments for the training program donated by MedShare, an organization which Doug Grey and I helped bring to the Bay Area. We have a 20,000 square foot facility in San Leandro loaded with medical equipment which we ship to hospitals and clinics in the developing world as well as free clinics in the United States. Lawrence Oresanya will begin the rotation today. Eveline Shue will continue in the fourth week of her rotation.

Midpoint Evaluation

We had a formal meeting with the faculty and residents last Thursday. All of the remarks were very positive. Of course, this is a very polite society but I do think they are pleased to have UCSF residents and a faculty member here. Everyone has been particularly kind and friendly to me and both firms (the one to which I am attached and the other one as well) continue to invite me to scrub on their difficult cases. The Tanzanian faculty heard my concern about the integration of our residents into the call schedule. They stated that starting this week, our residents will be on call with a Tanzanian resident and will alternated “first call”. That means that our residents will be called first one day and if the case is an operative case, our resident will do the case, with the Tanzanian resident assisting and in general I will be supervising (especially since the Tanzanian faculty do not usually appear at night for emergency cases). On alternate days, the Tanzanian resident will be on “first call” and our resident will assist them. This seems like a fair solution to our concern and both the Tanzanian faculty and residents have been very gracious I think in accommodating us. We will see how it works in practice.

Academic Program

In addition to the usual academic program outlined in previous reports, our group had three presentations this week: 1. Abdominal Tuberculosis—Jessica Beard, 2. Typhoid Fever—Surgical Complications – Eveline Shue, and Burn Care—Bill Schecter.

Recreational Activities

The days are long but there is down time on the weekends. There is an island reachable in 20 minutes by a Dhow with a nice beach, safe swimming and small restaurant serving grilled fish which is quite good. The spice island of Zanzibar is a 20 minute flight or a hour ferry ride. Last weekend, Gisela and I went to Zanzibar and stayed overnight at a beach hotel. It was very easy to arrange. We took a fascinating guided tour of Stonetown which has extensive Arab influence. I ran into some excellent Arabic speakers, which was a relief because my Swahili is still rudimentary at best. Stonetown was the last active slave market which closed only in 1873. You will learn a lot about the history of the slave trade and its abolition. Since I have been in East Africa, I have also increased my understanding of the Middle East since I did not previously appreciate the extent and duration of the close ties between Arabia, the Levant and East Africa.

There is also a town called Bagomoyo, the previous capitol of Tanganika before the development of Dar Es Salaam. It is 1 1/2 hours by Daladala (an overcrowded bus which is a fascinating experience but not for the faint of heart). The cost is less than $2.00. We stayed at a beach resort. You see Dhows cruising off the coast, either fishing or transporting produce to and from Zanzibar to Bagomoyo. We took another tour which was also very interesting and further increased our knowledge of the slave trade.

After you finish your rotation, it is definitely worth staying an extra week and taking a safari if you haven’t done it before. Last year we took a one week Safari to Lake Tangire, Lake Manyara, the Ngorogoro Crater, Olduvai Gorge and the Serengeti Plain. It is an unforgettable experience. Gisela, who has basically finished her TB work and is now in Swahili School, will take another Safari with her brother for a week while I am working.

Dining in Dar Es Salaam: There are reasonable Indian, Ethiopian and Thai restaurants in town. All are a cab ride away from the Kalenga House where we are staying. The Serena Hotel serves a good meal on an outdoor terrace. The food is good but if you are used to San Francisco cuisine, you are not coming to Dar Es Salaam to eat!

Overall Impression

We are continuing to have a very positive experience, are seeing a lot of cases and doing a reasonable amount of surgery.

Lawrence Oresanya arrived on Sunday, November 4, and will begin his rotation next week after Jessica Beard rotates off the Service. Last week we became more integrated into the service and both Jessica and Eveline worked on emergency and elective cases. We are seeing a lot of regular general surgery cases presenting with far advanced disease and fewer “tropical diseases” than I anticipated.

Academic Program

We are attending all the Department meetings and the Resident Teaching Conferences. The quality of the conferences varies but in general is quite high. In addition, both Jessica and Eveline are preparing case conferences for our own small group based on interesting cases that we have seen. I have also given a case conference to our residents and anticipate giving additional ones. Our days are quite long and so we are not having as many conferences as I anticipated (which is good in the sense that we are all very engaged clinically).

Security

A word about security: The Kalenga House where we are staying was originally built by UCSF for the XXXXX Program. This program has now ended and the Kalenga House has been turned over to the Muhimbili University. It is located within a walled compound and has a full time security guard (as do most establishments of this type in Africa in my experience). The door of the building within the compound is also kept locked most of the time unless one of the residents is in the common room. Valuables are safe within the rooms (which are also kept locked). It is a short walk from the Kalenga House to the gate of the Muhimbili National Hospital/Muhimbili University of Health Associated Sciences complex which is also a guarded walled compound. Walking in this area during the daytime is safe. There are few lights in Dar Es Salaam compared to most cities in the west. Women should not walk alone at night.

Midpoint Evaluation

This is the fourth week of our eight-week experimental program. I have scheduled a meeting for a midpoint formal evaluation with the Chair of Surgery and his faculty as well as our residents to take place on Thursday, November 9, 2012. Informal discussions indicate that Muhimbili residents and faculty are pleased with our presence. We have talked about ways of better integrating our residents into the call schedule (which has obvious challenges because fluency in Kiswahili is very important. However, this is a solvable problem and I anticipate a satisfactory resolution after Thursday based on the initial discussions. I have the feeling that everyone wants to make this work and there is a lot of good will and a minimum of politics (as best I can tell with my rudimentary Kiswahili!)

Challenges for the UCSF Residents and Faculty

1. The Kalenga House: The great advantage of the Kalenga House is the proximity to the hospital and the security. However, communal living is not for everyone and some future faculty members here for an extended stay may wish to live in an apartment. I will investigate this option. The most attractive places are near the beaches but the traffic in Dar Es Salaam is horrendous and traveling 3-5 kms at rush hour can sometimes take an hour or more. There are some apartment buildings near the hospital and I will also check these out.

2. Integrating into the Service: As in any new environment, learning how to make things work is a challenge, especially if you don’t speak the local language. However, our Tanzanian colleagues at every level have looked out for us and done their best to ease the transition.

3. The greatest challenge, particularly for the residents, is dealing emotionally with the level of pre- and postoperative care which of course is quite different than in the United States. Laboratory data is often non-existent and when available is usually at least 24 hours old. In essence, the patients are on automatic pilot. Concepts of ventilation and oxygenation are quite different than our own standards. Nutritional support is not available. Almost all food is supplied by the family. If the family doesn’t bring food, the patient doesn’t eat unless very special arrangements are made. This has been hard for the residents. On the other hand, these patients are incredibly resilient and have survived experiences which surprised me.

Eveline Shue arrived earlier this week and went straight to work the next and did an exploratory laparotomy. Eveline and Jessica took call together on Thursday and Thursday night working with Dr. Hussein Hassan Ali. They did a splenectomy and repair of a colon injury due to a GSW and a diverting colostomy for a malignant obstruction of the rectum due to advanced cervical cancer. We made ward and ICU rounds Friday. This week was a 4 day week because Friday was the Muslim Holiday of Eid as Adha celebrating the willingness of Abraham to sacrifice Ismail (Ishmael) before a ram was provided (the story in the Koran obviously differs from the one in Genesis). This Eid occurs at the end of the month of the Haj (The pilgrimage to Mecca) when the Hajis (the pilgrims) throw stones at the three devils on Mount Arafat outside of Mecca.

There were also a lot of interesting cases in clinic this week including patients with inflammatory carcinoma of the breast, carcinoma of the head of the pancreas (with a Courvoisier gallbladder), Graves Disease, gastric cancer, and a right neck unfortunately full of rock hard lymphadenopathy probably a metastatic head and neck tumor (perhaps laryngeal cancer, the patient was hoarse). Our residents are obviously being exposed to a lot of far advanced malignancy for which, unfortunately, little can be done.

ICU

Our patient with the 4 day old perforation of the 4th duodenum due to blunt trauma is doing well. He developed a sympathetic left pleural effusion (not surprising given what was going on in the lesser sac). We diagnosed it on physical examination and drained it. He still has a high ng output (also not surprising) but the main challenge is nutrition (we have no way to give nutrition at the moment unfortunately).

Impressions:

We have quickly become part of the service. The medical and institutional problems here are primarily economic and cultural but we are both making an educational contribution and learning a lot from our Tanzanian colleagues and our patients.

We (my wife Gisela and I) arrived by way of New York and London to Dar es Salaam. I think it is preferable to stop for 12-24 hours in Europe to rest so that recovery from jet lag is shortened and you can begin the clinical rotation in better physical shape after arrival. We arrived on a Friday morning. There is a direct flight from London to Dar es Salaam which takes about 9-10 hours. We were met by a driver from the Muhumbili University of Health Associated Sciences (MUHAS) and taken directly to the Kalenga House on Kalenga Road.

Accommodations

We arranged our transport and our accommodation at the Kalenga House through MUHAS which has a formal relationship with UCSF. Dr. Terry Reynolds, who is the Director of the Emergency Medicine Residency Program at MUHAS and resident in Dar es Salaam for most of last year, was very helpful in supplying this information.

The Kalenga House is a relatively new two story building with multiple rooms (small for two people), some of which contain private bathroom facilities and showers. All rooms have air conditioning (essential in Dar es Salaam—particularly at this time of year).

Initial Arrangements

We met Dr. Jessica Beard, our first UCSF Surgical Resident on rotation with me, at the Kalenga House. Jessica is doing research projects in Tanzania this year and is fluent in KiSwahili. She has been here for two months and has spent extensive time in East Africa previously. She was most helpful in getting us organized the first day. The key issues are:

1. Cell phone Service: You MUST have a cell phone to function in Africa. We immediately went to the Vodafone Store and bought cell phones for approximately $20.00. I also bought approximately $40.00 in minutes. Once you have a cell phone, you can function as your colleagues can (and will) reach you when they need you.

2. Internet Access: There is Wifi at the Kalenga House but at the present time it is HIGHLY unreliable. Thebest thing to do is buy a modem for your computer. You can also insert a Tanzanian SIM card in your IPAD but I elected not to do this as I didn’t wamt anyone fiddling with my IPAD (rightly or wrongly). Jessica advised us to go to the Zantelcellular company as their modem apparently is more reliable than

Vodafone. The modem cost about $40.00 and a similar fee for 5 gigabytes for one month of usage. This has been very reliable and the Internet Access relatively rapid. Perhaps we should have used Zantel for the cell phone as well. In any case, the process was relatively painless and within 2 hours we had cell phone and Internet Access.

3. Groceries: You will need to purchase groceries. The best grocery store is Shopper’s, an inexpensive cab ride from the Kalenga House. The kitchen in the Kalenga House is well equipped. If you are challenged in the kitchen (as I am—Gisela is near Arusha at the National TB Hospital for a week of work but will return today), there are plenty of Indian Restaurants which serve good food for dinner.

4. Recovery from the Trip: We spent most of the weekend resting and sleeping. We took Melatonin in the evenings and slept through the night. It was the easiest recovery from jet lag that I had ever had.

5. Cash: Barclay’s Bank ATM’s are a cab ride away and offer cash with your Debit Card at no cost for the transaction. There is an ATM within the hospital grounds that charges for the transaction

Department of Surgery Schedule

There are two surgery firms: 1 and 2. Firm 1’s focus is gastrointestinal disease and Firm 2’s focus is thoracic surgery. In practice they both do the same cases. Most of the “thoracic” work is chest tube insertion although they did a right thoracotomy to remove a giant fatty tumor arising from the mediastinum and occupying most of the pleural space—hopefully a giant lipoma although the histology is not yet back). Jessica and I elected to join Firm 1 and are functioning more or less as regular members of the Firm. The academic and clinical schedule for Firm 1 is listed below. The schedule for Firm 2 is the same except that they have a different operating and clinic schedule.

07:30-09:00 Resident Presentation Conference09:00-11:00 Grand Rounds—this is a major teaching rounds at the bedside with students presenting the cases and being grilled by the faculty. Everyone is dressed in white coats and standing at attention. All business work is conducted in English but social discussions occur in KiSwahili--this is the way bedside teaching used to be.

Friday

08:00-09:00 Ward Rounds09:00-pm Elective Surgery

Personnel:

In my next report I will submit a detailed list of the Department of Surgery personnel with contact information. As a brief overview, the Surgery Department is divided between the University surgeons and the Muhumbili National Hospital Surgeons. They all work together but as you can imagine, there are the usual political intrigues that are present in every University Department (of course we don’t have any of those problems at UCSF!). There are several young faculty members. Residency here is only 2 years. They are highly intelligent and highly motivated. Their enthusiasm for learning is both uplifting and infectious. They have an excellent fund of knowledge but their surgical repertoire and technique are limited. I showed up on Monday morning and immediately after the morning meeting they asked me to demonstrate a thyroidectomy in a patients with a large vascular goiter due to Graves Disease. I was amused as I thought they were pitching me (the new guy from San Francisco) a challenging case to see what kind of trouble I got into). Jessica spoke to them in KiSwahili afterwards and apparently no, they just wanted to see how to do a thyroidectomy. It was the first time that they had seen the recurrent laryngeal nerve. They usually just cut through the thyroid and not expose the nerve

(which is not a bad way to do it given the circumstances as they say they have few complications). Immediately after the thyroid, a young surgeon from Firm 2 asked if I would help him do a modified radical mastectomy. I helped his resident do and en-bloc mastectomy and axillary dissection removing all the nodes in a fascial envelope. They had never seen anything like this before and had never seen the intercostobrachial, long thoracic and thoracodorsal nerves in a clean axillary bed. All of their patients present late with bulky nodal disease in the axilla. I suspect they berry pick a couple of the biggest nodes in the axilla and go home as they were very concerned about dissecting out the axillary vein. At any rate, they were very appreciative and have since asked me to help with another modified radical mastectomy.

So in summary, we have been very well received by the students, residents and faculty and as far as I can tell there is no interpersonal tension or resentment caused by my presence. In fact, they have solicited my advice on many cases and followed it every time (hopefully for the patient’s benefit). On the other hand, I have modified my practice to a certain extent to make sure that both my operations and my advice did not violate their “comfort zone”. They know much more about their patients’ response to surgery and their diseases than I do right now. I am teaching basic surgical principles but following their lead otherwise.

Pre and Post Operative Care:

Our residents are not coming here to learn pre and post operative care. Residents and future faculty will have to be screened to make sure that they can emotionally tolerate the level of care and the interaction with patients that they will find here. If you are unwilling or unable to practice African Surgery, you will be very unhappy and likely create animosity that will endanger the sustainability of this effort should the Department decide to proceed after this trial effort. You will find patients lying around for many hours (or perhaps even a day or more) with peritonitis, intubated patients transported from the ICU breathing spontaneously through an endotracheal tube connected to the atmosphere with no oxygen, patients admitted to the surgery service in the ICU with a pH of 7.22 breathing at 50 times per minute without informing the surgeons. I discovered such a patient last night at 22:00 while visiting one of my patients there. You also have to be comfortable making clinical decisions including the decision to operate with little or no imaging (the CT scanner is broken) and almost no laboratory work. When there is lab work, it is often more than 24 hours old. There is one other point. You will meet many of your elective patients in the OR. They have been evaluated by someone else. You will probably be asked to assist a resident or demonstratethe operation yourself. Of course this is not the way we practice surgery nor do we want our residents to practice this way. However, I do a careful personal evaluation of the patient (briefly) and have proceeded—so far without any problems. If you have a real problem in the operating room, the “system” will probably not be able to rescue you as there is limited blood, most of the anesthetists are not physicians, and the ICU capability is limited. The nurses are diligent, hard working but do not have the education, training or skills of our ICU nurses. I mention all of this not to criticize this institution which is doing outstanding work but to emphasize that the people we recruit to this program (should you wish to continue it) must have the flexibility, the cultural sensitivity and the emotional stability to work in this environment. Our surgeons also must be comfortable doing a wide variety of cases as you will see with the case list I will present below.

There is only limited availability of mesh for herniorrhaphy. As you can see, I did a McVay repair for an elderly man with a direct inguinal hernia (I haven’t done one of these for 20 years as I consider it an obsolete operation and prefer mesh). However, it was the perfect solution in this situation and it was the first time that Jessica has seen a Cooper’s ligament repair (or the first time that my Tanzanian colleagues had seen one for that matter). They asked me to demonstrate a herniorrhaphy and I helped their resident with Jessica assisting. They do a Bassini repair, which is ok for an indirect hernia but probably not ideal for a complex direct hernia.

Clinic

My job in clinic was to listen to medical student presentations and make decisions with them on these patients. I worked with a Tanzanian resident. Jessica worked with the Head of Firm 1 in another room and saw an equally interesting group of patients. Breast cancer here is a huge problem and all of the patients I have seen so far have presented with either advanced or far advanced disease. Below is a list of the patients I personally saw in clinic on Tuesday with the medical students:

So far the experience is working out better than I had anticipated. My reception here has been warm and kind. Jessica is a known entity in the Department, speaks fluent KiSwahili and I visited last year and met most of the people when I negotiated the arrangement. I am sure these factors eased the transition. If I ever decide to make a major time commitment to Tanzania, I would go to school for a couple of months to learn KiSwahili. The doctors speak excellent English but very few patients speak English, most of the nurses speak only rudimentary English (and why should they, KiSwahili is their language), and the people on the street speak almost no English. I will send another report on our progress next week.